||| FROM DALE HEISINGER |||
I was troubled when I learned that Drs. Russell and Alperin have chosen not to pursue employment with Island Hospital when it assumes administrative responsibilities on April 1. Clearly, they have every right to define their personal directions, but it is unclear what they intend to do.
The whole purpose of establishing a Public Hospital District was the result of the ongoing economic challenges, i.e., no sustainable and reliable funding for the medical center, the inefficiencies of having two independent clinics, the cost of care, and the lack of a scope of care (after hours and weekend availability of call). Although we are grateful to the UW for stepping up to manage the medical clinic, they offered a model of care that was costly and still did not meet all of the medical needs that we, the citizens, desired.
In the past three years, the PHD Commissioners worked diligently to explore other options, but none of those options came to fruition except the one offered by Island Hospital. Our historical association with IH has been fraught with conflicts that resulted in their terminating our relationship with them on several past occasions. But the playing field has now changed. We now have a sustainable source of revenue, and IH has new administrative leadership, both of which suggest that our relationship is more viable.
The withdrawal of these two physicians certainly complicates the Commissioners agenda with only two months before IH assumes their new responsibilities. In addition, these physicians abandoned their commitment to our community, and the financial responsibilities that we, as taxpayers, made to establish a
sustainable, reliable, and excellent health care delivery model.
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How dare you claim that these two fine physicians abandoned anyone let alone an entire community! Where is there any law that says doctors need to give away their services at a loss and to personally go bankrupt to make people like you satisfied. Where is the contract between these private physicians and the Town of Orcas? If your new model is so great, you’ll attract dozens of doctors who will want to live in the Garden of Eden with you forever. Only time will tell if the pool of applicants will see it through your eyes. You owe these gentlemen and the entire community an apology.
Dale: My first reading of your comment regarding: “These physicians abandoned their commitment to our community, and the financial responsibilities that we, as taxpayers, made to establish a sustainable, reliable, and excellent health care delivery mode.” – well it bothered me. As I thought about it, I wondered what you had intended to convey (or communicate).
YES, we as a community have made a commitment (via a taxing district) to subsidize health care on the island – we voted to do so – collectively as a community. Our PHD Commissioners and staff have committed enormous sums of time in sorting out what they anticipate will be best for the Orcas community.
The two doctors (for whatever their personal reasons may be) have elected not to participate as PROVIDERS under the new arrangement with Island Hospital. That is their choice – and I don’t think you should criticize them personally.
Two unknowns exist (perhaps more). First, will Island hospital find doctors to work in the clinic – I am certain they will. The uncertainty rests in the relationships we will have to re establish with a ‘new doctor’ .
A second unknown is whether Dr. Russell or Dr. Alperin will open offices to compete with the Medical Clinic. If they choose to do so, it could undermine the viability of the model our commissioners and community have worked to establish for our collective good. This would bother me deeply, but I don’t they deserve direct criticism.
Dale,
With all due respect, I wish you would redact these comments. There is room in this community for a medical center that offers x ray, lab and urgent care services and back up for emergencies AND for private physician practices where the physician-patient relationship and accessibility can prevail.
Upon reflection, it seems that it is bureaucracies have been forced to leave Orcas over and over due to financial constraints and it is the physicians who have maintained care of their patients.
The IH-OICHD has committed to collaboration and innovation. There is no reason we can’t have it all on Orcas. In fact, in other industries collaboration has yielded better outcomes.
This is such on opportunity to find great ways to offer both on demand care and primary care. Not every health care worker fits every demand. There is a need for more health care workers, not less.
Since it is not appropriate for a wife and mother – physician to doctor their own family, Mine will likely follow their kind, competent and accessible doc to his new practice. I don’t view it as abandonment, but rather commitment.
In this difficult time, accusing hard working and weary physicians of abandonment in a local paper or on facebook is an unkind kick in the teeth. It will not foster the type of collaborative environment so needed in our community.
With high regard for your own service,
Camille Fleming MD, MBA
Please show where either of these doctors committed to work for the community regardless of the professional, financial, or managerial situation they are placed in. Last I knew, this was a free country and people are allowed to work for whomever they wish, where ever they desire, assuming they can be hired. If the community had paid for their education and they in turn committed to a number of years of providing care for the community your comment would be justified, but we didn’t and it isn’t. If you’re looking for indenture servants to serve your desires, perhaps you should look to a different country.
Thank you Dr. Fleming for your thoughts. I have the utmost respect for all doctors, nurses, and staff that work so tirelessly to keep us healthy.
I am mortified by this comment. I poured my heart into providing care in this community and rolled with multiple shifts before throwing in the towel. I am free to express the utter, gut wrenching heartbreak that came with that decision. I tried hard at grave emotional costs to myself out of a deep love and commitment to my patients to stay in practice. I can not speak for either of these physicians and I would not try to. I have had the pleasure of working with them both however. I can tell you that there is not a single individual in that building that has put anything less than their very heart into caring for this island. I can also say that any decision made is not made lightly. In fact, that is a wild understatement. I have never worked with a group of individuals that were more committed. From the front desk to the providers, folks have zero inkling of the absolute battle being waged on their behalf. Not one of those fine humans “goes to work” at a job. Every single one of them puts themselves aside in an act of love for this community. Whatever they need to do next should be applauded and supported. All of them. Every. Single. One.
Kirsten Pickard, ARNP
I am surprised that this character assassination was published.
For shame.
Individuals employed in our community who hold esteemed positions, live and work under a high level of scrutiny. Their persona becomes that of a “public figure”, especially under the backdrop of a small-town atmosphere. Too often we forget that these people, our teachers, doctors, business leaders are, in fact, private citizens.
While it is disappointing to see these capable and able physicians step away from the current clinic, scrutiny of their decision should be no more the business of you and I than any other employee working for any other business.
Had these been elected officials who had resigned or acted negligently in their positions and failed to properly represent the people who elected them – bring on the criticism. That is certainly not the case here and their decision to leave or any future employment decision they make is not for us to judge. I wish them both the best and remain confident in the work that the OIHD has performed on behalf of our entire community.
These fine physicians have proven their commitment to this community and their patients over and over again, and no comment by Dr. Heisinger can change that. If there is something so wrong with the new system that they all feel that they can’t participate, then we must consider what that problem is, fix it, and not blame them for seeking a different path. Bring committed to the community does not mean fitting into a system that clearly is wrong for them as individuals and practitioners.
Here we go again……
Looks like Dale Heisinger owes two doctors an apology or retraction. Or both.
There needs to be two apologies. one from Dale Heisenger, and one from The Orcasonian. I doubt if The Orcasonian will ever apologize. Remember when they published the “Occam’s Razor” cartoon that assassinated Rick Hughes’s campaign?
Neither of the physicians pilloried above had, to my knowledge, any contractual or moral obligation to contract with Island Hospital for ongoing work at OIMC. I expect that their contractual obligations ended with UW’s contract. This leads me to Dr. Fleming’s statement that the island can support many more providers than those employed in the OIMC. While I certainly understand that the organization of the OIMC in the past may have left the working physicians and staff there overwhelmed, it was my impression when demographics and viability were discussed years ago that the number of physicians we had on island (at least three practices) was higher than our population could support, using industry. Add to that the number of tourists seeking care, and subtract the number of Orcas residents who routinely get their care off-island.
The point of this is that the one underlying motivation for the creation of the Healthcare District was to ensure a financially viable Medical Center by subsidizing a central practice location with attendant staff and equipment. While the ideal for financial viability would then seem to be all physicians on island practicing there, neither the number of practitioners nor the number of practices can be or should be controlled by the government. That said, the District can and should limit its subsidies to the Medical Center that it has brought into being.
I would like to respond ton one small aspect of Peg Manning’s comment: The industry standard for family physicians indicates that each MD should be able to maintain a patient panel of approximately 2,000 individual patients. I, too, remember the discussion years ago which concluded that there were “too many” doctors on the island. At the time I came across an article which discussed panel size in relation to patients’ age and morbidities plus community resources. The conclusion was that the accepted industry standard was appropriate only in a more urban/suburban setting in which the physician had a broad age-range of patients as well as patients having access to urgent care centers and ready access to specialists. The older the patient demographic and the more rural the practice, the lower the expected patient panel size. The conclusion I came to based on our island demographics (i.e. a preponderance of older patients), the lack of ready access to specialists (which means the family physician here manages conditions/patients which would normally be seen by an internal medicine specialist), plus the necessity of urgent care being seen in the office, was that a patient panel of approximately 800 individual patients per physician seemed appropriate. If I can lay my hands on the article, I’ll post the link here, as it was very interesting and informative reading, and explains why we may need more physicians here than one might think.
The idea that the editors of the Orcasonian should be acting as a cheese strainer of ideas for our little community forum and judging each submission as to whether or not it’s opinions are “correct” enough to post is far more abhorrent than anything stated in the letter.
Some may judge the letter to be ill-informed or hurtful, but there is nothing derogatory or inciting about it. Why wouldn’t the Orcasonian publish an opinion piece from a community leader with relevant experience? Even when I personally disagree with the sentiment (which I do). And here you are free to comment and post your disagreement.
I for one am for a vigorous public debate and applaud them for publishing all manner of opinions, even if people vehemently disagree. Judge the content of the letter, and maybe even by extension the author, but don’t shoot the messenger. Feel free to return to your perfectly manicured Facebook feeds where you can unfollow or mute any person or group who ever dare have a differing opinion than you, but save the rest of us from your Orwellian nightmare.
I found Mrs. Russell’s letter provocative – what does a provider’s “panel size” mean to me? If there are, on average, four visits per year per patient (and older populations have more visits per year than average) then the doctor with a panel of 2,000 will have 8,000 visits per year and the doctor with 800 will have 3,200. Assuming that the doctors are full-time equivalents, the one with 2,000 patients will need to see 40 patients per day (again, on average) which means less than 10 minutes of patient interaction per visit. The doctor with 800 patients will need to see 16 patients per day which means nearly one-half hour per patient. I suspect that longer visit times result in better outcomes, improved patient satisfaction, and happier doctors.
Bill, you forgot to account for the time the doctor needs for paperwork, EHR’s, supervision, calling in to pharmacies, insurers for authorizations, etc. Most metrics show that doctors spend at least 40% of our time on non-direct care necessities and in some studies up to 60%. It’s nice that so many non-MD’s are trying to figure out how a doctor’s practice actually runs. I am quite sure the doctors on Orcas would be glad to tell you how they actually try to do their work right there.
As for subsidizing care, Orcasians voted to do that, and perhaps the dollars should follow the patient/resident and not the practice, the same argument made in statewide educational funding debates? Any doctor who wanted to open an office on Orcas could and they would all compete on a level playing ground. Or, they could also create a shared pool for certain resources such as labs/imaging but not office space? There are many posssibe solutions, but the reality is even bad health care is very expensive, especially in a rural community with an aging population.
I found Dr. Heisinger’s recent condemnation of two Orcas Clinic physicians who are well-known for their commitment to patient care to be unfortunate. Competent doctors and medical organizations can take different approaches to their allocation of limited resources in pursuit of high quality patient care and disagreements are to be expected. As an example, my sister recently retired as a solo practitioner of family medicine in Port Angeles. She chose this path so that she could restrict her average daily appointments to twelve allowing for at least a half-hour of face time with her patients on each visit. Her “panel” of patients was less than 800. She chose this path in spite of earning less than half of that of her colleagues employed by local clinics and hospitals who were expected to see as many as 32 patients per day with only 10 minutes (or less) of face time per patient. I understand why a medical organization would establish such a high goal for visits per day – more visits can generate more revenue which can be used to offset losses from other practice areas (such as walk-in, after-hours, and emergency care). This is a reminder that not only is there no free lunch but that costs can be incurred not only in dollars but in reduced quality of service. I don’t know what Island Hospital expects for a visit rate from its providers and I don’t know if this was an area of contention between IH and the two physicians. But I do know that both Drs. Russell and Alperin demonstrated a deep caring for their patients and deserve our respect and gratitude for their service to our community.
As I understand and have seen with my primary, you get 20 minutes with them. For someone like me, who has had type 1 diabetes for 45 year, who is in good health and takes very good control of my diabetes, it is sufficient. For someone who’s older and/or who’s having multiple complications, this is not nearly enough time to do right by their patient.
Oh boo-hoo Dale Heisinger, sounds like herding local physicians into the PHD model offered didn’t work out as you thought. To make matters worse, your sanctimonious attitude attitude towards their previous service has been challenged by many followers regarding the fine medical service they’ve received from them. Who are your to determine, ‘What they (physicians) intend to the do,’ and whether, ‘The physicians abandon their commitment to the community.” Perhaps a more transparent proposal from both sides would prevent some of the animosity growing across the Island. Are the contract offers from Island Hospital available for public review ? I’ve heard the Orcas Island Health meetings can be streamed on the internet but we have no internet where we live and I’ve not heard or read where we can observe previous saved episodes. Times are changing Dale and surely something as important as health care on Orcas Island can be managed with cooperation and consent of the majority of the community rather than the assignment of methods of treatment and loss of qualified physicians by a few.
Neil, I didn’t forget, but I did neglect to go through the details as carefully as I should have. Twelve appointments in an 8 hour work day give you 40 minutes per appointment and 60% of patient face time puts you in the examining room for 24 minutes (which I casually rounded up to a half hour per patient.) Sixteen appointments per day give you 30 minutes per appointment or 18 minutes of face time (definitely not a half hour). Thank you for pointing out that non-direct care can be half or more of an appointment’s total time. Ed Andrews states that he finds his 20 minutes of time with his primary care physician to be sufficient. Your point shows that his PCP had better not be scheduling many more than 16 appointments per day in order for 20 minutes to be available for all visits. In contrast, 32 appointments per day give 15 minutes per appointment with only 6 to 9 minutes of face time with the doctor.
Bill, it is apparent that you fashion yourself an authority on medical practice management. But, unless you have run an office yourself and dealt with these things, show some respect for the doctors trying to make it all work. You also have done nothing to address the economics, only the issue of time. Why not go get the training to be a doctor (only 30 years for me, ending with a debt of $250,000 mostly at 18-21% interest since I got loans through HEAL when Cater was President and then Regan made that interest non-deductable!) and a MBA, and then present the perfect answer since you seem to believe you know how to fix health care after many others have been unable to do so. The reality is that most MD’s are seeing at least 40 patients/day, and doing the paperwork, labs, calls, practice management, supervision, prior authorizations etc. and it’s crushing. I spent 2.5 hours today on the phone getting generic medication approved by insurers/pharmacies for just 3 patients! My day started at 6 AM in the office. It’s 8:30 PM now and I have two more patient calls left to return. Oh, and I need to make sure I get in 50 hours of CME this year for licensure and the medical license for each state in which I manage patients (law requires a license in every sate where a pt. resides if you are to talk to them or do telemed) run about 500/state/year! Now med-mal insurance depending on field of practice is anywhere between 10,000 and 120,000/year. Oh, you might need to pay a nurse/PA, or support staff, rent, electric, Internet, and if you have any equipment there is rental/lease/purchase to figure in. You need to stop the fantasy about how simple this all is. Now most insurers pay 50-65.00 for an office visit. Do some math and let us all know how a solo doctor on Orcas is making it happen for the community, one that is older, sicker, needs/wants more face time, and is largely Medicare/Medicaid covered.
Dr. Kaye, Mr. Bangs can certainly speak for himself, but the “numbers” discussion began when I responded to a comment regarding “industry standards.” Number of patients, size of patient panel, etc. being only one aspect of medical practice (as I can attest to from personal experience), my larger point was that when one is looking at a specific practice location – Orcas Island, specifically – trying to apply industry standards may not be entirely appropriate. Sure, use them as a starting place, but then dig into the actual conditions on the ground, adapt as necessary, but first and foremost discern what is most important for you as a physician and for the community which you serve.
Is it possible for a solo doc to “do it all?” No. Is it possible for a solo doc, with reasonable limitations on his/her practice, to practice in a way that is healthy both for him and his family and puts the care of the patient as well as the physician-patient relationship near the top of the list of priorities? Yes, I believe it is, though it is challenging and requires a lot of thinking outside of the box. Is it possible on Orcas Island? That is a tougher question to answer, and will depend upon how business-savvy the practice is, how well they “play the insurance game,” and how well expectations are managed (to name only a few considerations).
Orcas weeps. For all who are smug about our rarified island “community” please honor and respect the pathways of each individual who falls into our midst.
Michelle, I appreciate your comments and insights. Many thanks, and lease stay safe and healthy. And we agree that Orcas is unique as are many smaller communities across our country.
Dr. Kaye, thank you for pointing out how challenging it can be for a physician today. As you’ve acknowledged, our health care lives on Orcas are challenging as well. But we are fortunate to have a dedicated health care district striving to provide us with an appropriate, affordable, and sustainable system. And we are fortunate to have doctors who are willing to explore innovative, alternative approaches. I am grateful for our new clinic and for our doctors who are all doing their best to keep Orcas healthy.
Lin can I nominate Ms. Spees to be quoted on your mast head?
“Honor and respect the pathways of each individual who falls into our midst.”
In the days of the Old Republic we called that tolerance. A bygone era.